TBI: Physical Therapy Management Flashcards
(153 cards)
1
Q
Describe a typical course of rehab for a patient with TBI
A
- ICU to acute care to inpatient to longterm care facility to outpatient rehab to community based programs to vocational re entry to exercise programs
2
Q
When should TBI rehab therapy be started?
A
- No set standard patient/provider dependent
- Team decision
3
Q
What are the 2 primary reasons for starting TBI rehab therapy?
A
- Normalize of ICP ( less than 20mmHg, patient dependent)
- Hemodynamic stability
4
Q
Name some neuromuscular impairments after TBI
A
- Impaired motor control
- Impaired coordination
- Hemiparesis
- Hypertonicity (abnormal postural reflexes)
- Somatosensory impairment
- Impaired postural control
5
Q
Name some behavioral impairments after TBI
A
- Easily frustrated
- Agitation
- Mental inflexibility
- Impulsivity
- Disinhibition
- Emotional lability
- Irritability
6
Q
Name some cognitive impairments
A
- Arousal/ Disorder of consciousness
- Attention
- Concentration
- Memory
- Learning
- Executive functions
7
Q
What is the patient unable to do if they have Post Traumatic Amnesia (PTA)?
A
Unable to form new memories
8
Q
How does a neuropsychologist determine the patients length of PTA?
A
Reassessing cognitive status and ability to form new memories daily
9
Q
What must a patient be able to do in order to demonstrate they are out of a state of confusion?
A
Must be able to identify specifics of date, time, place, and situation consistently
10
Q
T/F: Patients will typically have aphasia after TBI
A
false- they will have communication/language (dysphagia) impairments but not typically aphasia
11
Q
T/F: A patient after TBI may have visual and perceptual deficits
A
True
12
Q
Name some medication used in post-acute phase to address tone
A
- baclofen
- diazepam
- dantrolene
13
Q
Name some medication used in post-acute phase to address seizure control
A
- Anti epileptics
- Depakote
- Keppra (Levitiracetam)
- Dilantin (phenytoin)
- Cerebyx (fosphenytoin)
14
Q
Name some medication used in post-acute phase to address attention
A
- Neurostimulants
- Dopamine
15
Q
Name some medication used in post-acute phase to address arousal
A
- Amantadine (4-16 wks after dx)**
- Methylphenidate
- Bromocriptine
16
Q
Name some medication used in post-acute phase to address depression
A
Nontricyclic meds are most effective
17
Q
What are some activity limitations a patient may exhibit post TBI?
A
- Ambulation
- Basic mobility
- ADLs
18
Q
What are some participation restrictions a patient may exhibit post TBI?
A
- Return to employment
- Family role
- Community/social role
19
Q
Knowledge Checkpoint question: When do we start PT rehab for a patient after brain injury?
A
Vitals & ICP stability
20
Q
Knowledge Checkpoint question:
Which of the following impairments is common after brain injury?
- Amnesia
- Apathy
- Aphasia
- Hypotoncity
A
Amnesia
21
Q
Knowledge Checkpoint question:
Which of the following medications has been shown to address a secondary complication of seizures?
- Amantadine
- Baclofen
- Dopamine
- Keppra
A
Keppra
22
Q
What Rancho is a low level patient?
A
Rancho I-III
23
Q
What are the PT goals for patients in levels I-III?
A
- Consistently assess level of consciousness & track progress
- Increase arousal & functional mobility
- Improve tolerance to upright
- Reduce risk of secondary impairments
- Improve or retain joint integrity & ROM
- Educate family & caregivers
- Maintain coordinated care among all team member
24
Q
What impacts a patient’s ability to respond to stimuli & commands?
A
- Limited motor function
- Communication impairments
- Sedating meds
- Impaired sensation
- Impaired cognition
25
Describe Coma Rancho Level I
- Unresponsive to any stimuli
- Arousal system not functioning
- Eyes closed, often ventilator dependent
- No auditory, visual, cognitive, communication function
26
Describe Unresponsive Wakefulness Rancho Level II
- Awake but not aware
- Able to respond to external & internal stimuli
- Basic brainstem functions only
- Minimal communication w/ cortex
- Spontaneous eye opening
- Restoration of sleep/wake cycles
- Differentiate from locked in syndrome
- May startle to visual or auditory stimuli (or inconsistently localize sound)
- Not able to follow commands or communicate
- Reflexive smiling/crying/yawning, chewing may be present
- Withdraw/posture to noxious stimuli
27
Describe minimally conscious state Rancho Level III
- Awake & partially aware
- Inconsistent cognitively mediated behavior, different from reflexes
28
To be in a minimally conscious state Rancho Level III a patient needs to be able to do one or more of what tasks?
- Follow simple commands
- Gestural or verbal ("yes/no") responses
- Intelligible verbalization
- Movement or emotional behavior that occur in relation to relevant stimuli, not attributable to reflexive activity
29
What are some of examples of minimally conscious state?
- Smiling or crying in response to verbal or visual emotional content
- Vocalization or gestures that occur in direct response to verbal comments or question
- Reaching for objects that demonstrates a clear relationship between location & direction of reach
- Touching or holding objects in a manner that accommodates the size/shape of the object
- Visual fixation & tracking
- Inconsistently following commands
- Unable to functionally communicate thoughts/feelings
30
To emerge from minimally conscious state a patient must demonstrate reliable & consistent demonstration of one or both of what actions?
- Accurate yes/no responses to 6/6 situational questions on 2 consecutive examination
- Functional use of a least 2 different objects
31
What is the gold standard outcome measure for assessing levels of consciousness?
Coma Recovery Scale Revised (CRS-R)
32
Name the SOMs that can be used to assess levels of consciousness
- Coma Recovery Scale Revised
- Disorders of Consciousness Scale
- Rancho Los Amigos Levels of Cognitive Functioning
33
How is Multi-Modal Sensory Stimulation programs implemented?
- Controlled & structured manner
- Multi-sensory
- Balance of stimulation & rest
- Monitor patient response
- Use outcome measure to assess change
34
How is Familiar Auditory stimulation training performed?
5 minute story telling by patient relatives that involve autobiographical events
35
What does Familiar Auditory stimulation improve?
Improvement in CRS & increased activation of language areas on functional MRI
36
What are the benefits of Music Therapy in MCS?
- Behavioral improvement (more eye contact & smiles)
- Improved BP in MCS
- Greater activation of auditory network & physical responses (possible enhancement in attention)
37
Which is better music alone or movement with music interventions?
Supported sitting on trampoline with vertical motions & listening to music (3x/d x 7 min) > music alone
38
When is multimodal stimulation more effective MCS or VS/UWS?
MCS > VS/UWS
39
How should Multi- Modal Sensory Stimulation Programs be implemented?
- Tailor to client tolerance & preference
- Begin early & perform frequently (3-5x/d, 7-20 min, for at least 2 wks)
- Avoid overstimulating
- Non distracting environment
- Give pt time to respond
- Use until more complex activity is possible
40
What does bi-modal and multi- modal mean?
- Bi Modal: Auditory & tactile
- Multi Modal: All 5 senses
41
Why should early mobilization be implemented?
- Shorter length of stay
- Increase chance of d/c to home
- Decreased secondary complications
- Improved outcomes (neuroplastic changes)
42
What are the contraindications to early mobilization?
- Unstable Spine
- Increased (ing) ICP
43
What are the precautions to early mobilization?
- WB restriction
- Skin/Joint integrity
- Autonomic instability
- CV status
44
How should early mobilization be implemented?
- Mobility to varied positions relative to gravity
- Monitor vitals closely
45
What is the goal of early mobility?
- Increase alertness with stimulation in different positions/ environment
- Improve level of consciousness
- Improve GI motility, ROM, CV response
46
What are some secondary impairments that can be prevented with early mobility?
- Contractures
- Pressure sores
- Pneumonia
- DVT
47
How often should a patient weight shift when in a wheelchair?
Every 30 min for 2 min
48
What is the positioning in bed and how often should the patient be turned?
- Hips/knees slightly flexed
- Turn every 2 hours
49
What should be prioritized when positioning?
- Management of mm tightness & joint stiffness
- Stretching
- WB
- Splinting
- Serial Casting
50
What is a risk factor if patients aren't properly positioned?
Neurogenic Heterotrophic Ossification
51
What are the clinical consideration of serial casting?
- Help to improve PROM
- Used in various neurologic conditions including pediatrics
52
What is serial casting proven to improve?
PROM
53
What are the 4 main ideas of family education & support?
- Maintain open communication
- Involve the family in POC & decisions
- Educate on current evidence when appropriate
- Provide realistic & consistent messages
54
What is the practice guidelines for patients in Severe Disorder of Consciousness
- Multidisciplinary Rehab
- Use SOM
- Can use electrophysiological tests for dx when in doubt
- Prognosis may still be favorable >28days
- Be aware & treat confounding medical complications
- MD prescribe Amantadine to increase arousal at 4 weeks
- Counsel families
55
What are the tips for patient interaction in Rancho Levels I-III?
- Treat the patient with respect & dignity
- Explain what you are doing & why
- avoid stimulation
- Allow time for responses
-Model behavior for the family's interaction with the patient
- Frequently re orient the patient
56
Patients who are in what stage? at 1 month after TBI have a 50% chance of regaining consciousness
UWS
57
20% recovery in VS or MCS to full consciousness within 6 weeks of discharge from inpatient rehab. What did all the patients have in common?
- Initial GCS average was a 9
- 3-8x more likely to recover target behavior on CRS if in MCS
- Preserved language function had best prognosis
- 20% of VS was able to consistently follow commands
58
How long do patients need to be in Chronic (Persistent) Vegetative State/Unresponsive Wakefulness before there is a minimal chance of waking up?
- >12 months in traumatic injury
- > 3 months in non traumatic injury
59
The more time of altered consciousness the (worse or better) the outcome
Worse
60
Describe Level IV: Confused- Agitated
- Heightened state of activity
- Behavior is not purposeful & bizarre relevant to environment
- Patient is driven by confusion
- Attention is extremely brief
- Memory, both long term & short term are impaired
- Patient may be aggressive
- Unable to cooperate directly with treatment effects
- Unable to learn new info
61
T/F: Patients in level IV are mean and intending to hurt others
False
62
T/F: Patient in LOCF IV does not need a lot of people to manage their safety
True - myth that you need a lot of people to manage the patient safely
63
T/F: Medication is required to calm the patient down if they are in LOCF IV
False
64
T/F: The patient is not deliberately not cooperating with therapist in LOCF IV
True
65
T/F: In LOCF IV the way the patient acts is not who they are as a person
True
66
T/F: When a patient is in LOCF IV you should educate the patient that aggressive behavior last for the rest of their life
False- Educate that aggressive behavior typically occurs only for a few weeks at most
67
What is the primary examination goal of a patient in LOCF IV Confused and Agitated?
- Identify behavioral & cognitive concerns
- Ability to sustain attention & Distractibility
- Identify impairments & activity limitation to determine overall function
68
T/F: The primary goal when a patient is in LOCF IV is to progress function
False- Not necessarily the primary goal
69
What should be focused on when working with a patient in LOCF IV?
- Use familiar activities & focus on participation & tolerance to session
- May need to end early if agitation is too great
70
What are some challenges when working with a patient in LOCF IV Confused & agitated?
- Amnesia
- Confused
- Decrease attention
- Distracted
- Uncooperative
- Agitation
- Agression
- Impaired insight into deficits
71
What type of environment should a patient in LOCF IV Confused & agitated be in?
- Closed
- Freedom to move
- Low distraction
- Dim lighting
- Choose when to have family present (one at a time)
72
How can you practice consistency with a patient in LOCF IV Confused & agitated?
- Address inappropriate behaviors in a consistent manner
- Re orient frequently
- Follow consistent schedule
- Use daily charts, graphs or logs
73
When a patient is in LOCF IV Confused & agitated will there be carry over of newly taught tasks?
- No carry over over of non-automatic tasks
- No new learning
74
T/F: When choosing activities for patient in LOCF IV Confused & agitated you should not change up the exercise and get them to do the planned activities.
False - Change activities frequently and do not force them to do things because this will increase agitation
75
What type of practice is best for a patient in LOCF IV Confused & agitated ?
Distributed because they need rest time
76
T/F: Longer treatment session are beneficial for patients in LOCF IV Confused & agitated
False
77
What activities should be chosen when working with a patient in LOCF IV Confused & agitated ?
Functional tasks whenever possible that are near the patient's physical level
78
What type of activities can help diffuse agitation for a patient in LOCF IV Confused & agitated ?
Repetitive and automatic
79
How can you model calm behavior for a patient in LOCF IV Confused & agitated ?
- Be in control of your emotion
- Use calm, slower tone
- Get on patient level
- Re direct patient if needed
80
How should you communicate with a patient in LOCF IV Confused & agitated ?
- Be clear & concise
- Be mindful of your nonverbal communication
- Start with simple questions/commands
81
T/F: Expect egocentricity from patients in LOCF IV Confused & agitated
True - Patient doesn't see your POV they can only think of themself
82
What are some things you can do to promote safety of the patient when they are in LOCF IV Confused & agitated ?
- Helment
- G Tube/Trach
- Craniectomy
- Locked unit
- Posey mitt when not with you
83
What are some ways a PT can maintain safety of themselves when working with a patient in LOCF IV Confused & agitated ?
- look out for signs of increasing agitation/aggression
- Get help when needed (Behavior response team)
- Maintain access route out of room (keep self closest to door)
- Be aware of clothing/jewerly
84
Describe the Behavior Modification Program
- Positive reinforcement (reward system)
- Re direction
- Structure w/ consistent responses to inappropriate behavior
- All team members on board (including family)
85
Which management approach should be first when working with a patient in LOCF IV Confused & agitated (Behavior or medical) ?
Behavioral
86
When and what types of medications should be used with a patient in LOCF IV Confused & agitated ?
- At times required to maintain safety of patient, family or staff
- Try to minimize use
- propranolol, trazadine, SSRIs, Tegretol, Seroquel
- Ativan (benzodiazepines) only in severe agitation
87
What type of learning is possible for patient in LOCF IV Confused & agitated ?
- Motor relearning
- Formerly learned skills that were practices a lot can be regrained (ie walking or reaching)
88
What are some appropriate goals for patients in LOCF IV Confused & agitated ?
- Improve endurance
- Improve activity tolerance
- Improve attention to task
- Family education & support
- Prevent agitation through environmental medication & graded stimuli
- Help patient learn to control their behavior
89
Describe LOCF Level V: Confused- Inappropriate
- Patient is now able to follow simple commands fairly consistently
- If environment/ task is more complex the patient's responses are more non-purposeful & random
- W/ structured environment may be able to socialize on an automative level for short periods
- Extremely distractible
- Verbalizations, inappropriate, confabulatory
- Memory is severely impaired
- Unable to learn new info
- Poor safety awareness
90
Describe LOCF Level VI: Confused- Appropriate
- Goal directed behavior w/ external input
- Recognizes basic needs & performs automatic tasks (Continent & Able to help w/ ADLs)
- Shows carryover of re-learned tasks
- Follows simple commands consistently
- Able to follow a schedule with structure
- Memory problems
- Poor insight into cognitive deficits
91
What LOCF level will show carryover of relearned tasks?
Level VI Confused-Appropriate
92
What memory problems do patients in LOCF VI Confused- Appropriate have?
Long term memory is better than short term
93
What are the treatment goals for Levels V & VI?
- Increase safety & independence w/ mobility & ADL's
- Improve postural control, balance, & gait
- Improve strength & endurance
- Patient & family education (considering cognitive & behavior concerns)
94
Is formalized testing possible when a patient is at level V or VI?
Yes
95
How should formalized testing be administered when a patient is at level V or VI?
- May need to complete in several short sessions
- Keep distractions concise
- Determine focal injury deficits
96
Is new learning possible in level V or VI?
No they are still confused
97
T/F: Patients have poor safety awareness in levels V & VI
True- still needs supervision
98
T/F: A patient in LOCF V or VI does not have memory deficits
False
99
T/F: Frequent re-orientation to situation, place, date, & time is needed for patients in LOCF V or VI
True
100
What type of environment should treatment of patients in Levels V/VI occur in?
- Meaningful environment
- Reduce distractions
101
How should treatment sessions for patients in Level V/VI be implemented and what tasks should be selected?
- Start with short PT sessions or incorporate breaks
- Limit task complexity
- Provide structure & routine
- Saliency
102
Name some intervention examples that can be used for patient in Level V/VI?
- Ball toss while maintaining standing balance
- Kicking a ball/basketball/lacrosse
- STS transfer training while reaching for various colored targets
- Navigate to/from therapy gym back to room
- Stair training
- Slowly begin to increase the cognitive load (sequencing, command following, visual scanning, social interaction w/ staff)
103
What communication strategies should be implemented when working with patients in levels V/VI?
- Repeat info as needed
- Use a memory planner
- Avoid asking too many questions
- Explain what is going on
- Allow time for processing & response
104
What is Moss Attention Rating Scale used for and at what level is it valid?
- Observational tool which evaluates attention after TBI
- Valid LOCF IV or higher
105
What does Orientation Log measure?
Orientation to time, place & circumstance
106
What does Galveston Orientation & Amnesia Test measure?
PTA through orientation questions
107
What outcome measure are appropriate for examining balance in patients in V/VI?
- Berg Balance Scale
- Community Balance & Mobility scale (typically later stage)
- High Level Mobility Assessment Tool (typically later stage)
108
What outcome measures can examine attention & cognition in patient in V/VI?
- Moss attention rating scale
- Orientation log
- Galveston Orientation & Amnesia Test
109
At what LOCF is a patient out of PTA?
Level VII
110
Describe Level VII: Automatic- Appropriate
- Patient is now oriented in environment
- Follows daily schedule & routine in a robot like way
- Unable to recall all the details of daily events
- New learning possible with extra time
- Ongoing safety concerns & Impaired judgement
111
Describe Level VIII: Purposeful - Appropriate
- Able to recall & integrate past & recent events
- Aware of & responsive to the environment
- Independent in the home
- Developing community reentry skills
- Shows carryover with new skills & no supervision required once skill is learned
- May continue to demonstrate decreased abilities as compared to premorbid status
- Vocational/drivers training may be appropriate
112
At what level can new learning occur?
Level VII
113
Patients in Levels VII & VIII are more oriented (no PTA) what is the difference between the two?
- VII: robot like, impaired judgement
- VIII: Responsive to environment, does not require supervision once activities learned, struggles with new situation
114
T/F: During examination of patients in Levels VII & VIII you can identify more focal injuries and typically examine gait & balance in greater depth than previous levels
True
115
What are rehab goals centered around for patient in Levels VII & VIII?
- Helping the patient function w/ less structure
- Improving independent problem solving & decision making
- Increasing safety awareness & insight (Often anosognosia)
- Decreasing assistance & supervision
- Integrating cognitive, emotional & social skills needed to function in the community
116
What is anosognosia?
Lack of insight
117
What do cognitive rehab programs aim to do?
- Promote community reintegration
- Return to work/school
- Address behavioral, psychosocial & cognitive impairments after TBI
118
What are some cognitive intervention strategies for patients in levels VII & VIII?
- High level balance & walking skills
- Dual task
- Provide opportunities for problem solving
- Enhancing social skills
119
What type of practice and feedback would be appropriate for patient in LOCF IV- VI?
- Distributed
- Extrinsic
120
What types of practice and feedback may be considered for a patient in LOCF VII-VIII?
- Massed practice
- Self-generalization feedback
- Video self- monitoring feedback
121
What are some ways you can develop awareness patients in Levels VII & VIII?
- Actively involve patient
- Allow patient to make mistakes in safe environment
- Ask patient to predict future performance
- Ask patient for self-assessment after task completion
- Provide cueing & assistance in systematic manner to allow patient to perform as much of problem solving as possible
122
What are some signs of fatigue in patients?
- Increased irritability
- Decreased attention & concentration
- Deterioration in performance of physical skill
- Delayed initiation
123
What are some strategies to maximize outcomes for all patients at all levels of cognitive functioning in all rehab settings?
- Beware of overstimulating the patient
- Gradually increase cognitive complexity when appropriate
- Use a structured organizational system
124
What are some outcome measures that can examine balance in patients in levels VII & VIII?
- Community Balance & Mobility Scale
- HiMAT
125
What are some outcome measures that can examine gait in patients in levels VII & VIII?
- 6MWT
- 10 MWT
- Functional gait assessment (FGA)
- Rancho Los Amigos Observational Gait Analysis
126
What outcome measures can examine QOL in patients in levels VII & VIII?
- Quality of Life after Brain Injury
- Community Integration Questionnaire
127
What outcome measure can examine overall function in patients?
Functional Assessment Measure/ Quality Indicators - Inpt settings
128
What is a compensatory based interventions?
- Improve functional skills by compensating for lost ability
- Brain activation in areas formerly not used for a given task
129
What is a restorative (Recovery) Approach?
- Restore normal use of the movement pattern
- Reactivate areas of the brain, or penumbra, typically responsible for the task
130
What are some examples of compensatory approaches?
- Using an alternative motor pattern or strategy
- Increased time
- Increased cuing
- Assistive Device
131
What is the over arching goal of intervention strategies?
Intensive, challenging, meaningful & Task specific to promote motor cortex changes and functional recovery
132
At what frequency should constraint induced movement therapy be performed?
- 6hrs/day
- 2-3x/week
- Population may require more support & structure
133
How should locomotor training with BWS be implemented?
- Parameters not fully understood
- Chronic patients with TBI
- 45 min, 3x/wk, 18 sessions
134
Why do patients have severe deconditioning following TBI?
- Period of bed rest & immobility
- More likely to develop a sedentary lifestyle
- Decreased aerobic capacity
135
T/F: TBI does not affect life expectancy
False- shorter life expectancy by 7 years
- 3x more likely to die of CV disease, CVA, & thromboembolic disease
136
Patients after TBI have an increased risk of what?
- Alzheimers, (early onset) Dementia
- Parkinson Disease
- Mental Health & emotional concerns
- Fatigue
- Sleep disturbances
137
What are the benefits of aerobic conditioning?
- Reduce long term CV risks
- Improve aerobic capacity (VO2 max)
- Improved sleep
- Decrease fatigue
- Decreased depression & anxiety
- Improved cognitive function
138
What should aerobic conditioning be dosed at?
- 60-90% of age predicted max HR
- RPE scale: Somewhat hard to vigorous (12-16)
- 20 -40 min per session
- 3-4 days/wk
139
What is the dosage of resistance training?
2-3 days/wk, 3x8-12 reps (10 rep max)
140
What are some interventions for balance?
- Agility training
- Challenging environmental conditions
- Dual task
141
Name some negative prognostic indicators
- Low initial GCS score
- No pupillary response
- Age (<5 or older adult)
- Low educational level
- Hypoxia
- Coma > 2wk
- High ICP (>20mmHg)
- Hyperthermia within 72 hrs of injury
- Brain bleed
- Obliteration of 3rd ventricle or basal cisterns
- Midline shift (herniation)
142
What are some positive prognostic indicators
Multidisciplinary intensive rehab has been shown to be effective in improving consciousness & body function
143
If a patient is in PTA <48.5 days what is the typical outcome?
Higher FIM score at d/c from inpt rehab
144
If a patient is in PTA <27 days what is the outcome?
More likely to be employed
145
If a patient is in PTA <34days what is the outcome?
Good overall recovery
146
If a patient is in PTA <53 days what is the outcome?
Live w/o assistance
147
In terms of prognosis what is it an older adults?
- Longer length of stay in rehab
- a slower functional recovery
- Greater cognitive impairment at discharge
- 2x greater chance of nursing home placement
148
Why are there poorer outcomes in older patients?
- Brain has decreased capacity for repair as it ages
- Increased frequency of systemic complications after injury
- More often have preexisting conditions
149
Young brains has time to heal, some cognitive deficits may not manifest until later. When and what are some deficits?
- School aged
- Attention
- Increased processing time
150
T/F: After TBI a majority of patients are employed at 5 years
False- 55% unemployed at 5 years
151
T/F: Patients after TBI are at high risk of depression & Anxiety
True
152
T/F: Patients after TBI are at higher risk of developing PD, Alzheimer's, Dementia, CTE
True
153
T/F: Seizure, accidental drug poisoning, infections & pneumonia are all examples of long term negative effects after TBI
True
